Waiting for the miracle

The SIUT staff:“It is teamwork,” says Prof Adibul Hasan Rizvi sitting sixth from left with Prof Rela on his right).

By Zubeida Mustafa

It is estimated that 2,000 children (may be even more) die of liver failure in Pakistan every year when their lives could be saved by a liver ansplantation

AT last, there is a ray of hope for those suffering from serious liver disease in Pakistan. Even patients with endstage liver failure will be able to obtain, in the not too distant future, the same treatment available in Europe and America, namely, a liver transplantation.

This might appear like dreaming for the moon in a country where the public health sector is so cash-strapped and transplant surgery so costly. But miracles are known to happen even in societies as underdeveloped and impoverished as ours, if there is someone to show the way.

It was a little over a decade ago that this paper was celebrating Karachi’s first kidney transplant in the Urology Ward of the Civil Hospital which was later upgraded by the Sindh government (and deservingly so) to Sindh Institute of Urology and Transplantation. And now the SIUT, which is set to expand into a 300-bed centre in the Dewan Farooq Medical Complex as soon as funds are available, has set its sights on liver surgery.

With Professor Adibul Hasan Rizvi at the helm, one can be confident that this goal is achievable. This modest, self-effacing surgeon, who refuses to take credit for his phenomenal successes — “it is teamwork” he insists — never despairs even in the face of heavy odds. His commitment to his vision and goals is so unwavering.

As the first step in this legendary journey of a thousand miles, Dr Rizvi invited the eminent liver transplantologist, Professor Mohamad Rela of the Liver Transplant Unit of King’s College Hospital, London, over to Karachi.

Accompanied by his anaesthetist, John Sedgwick, ,and theatre sister, Melinda Yui, Professor Rela stayed in the city for a week and performed two liver resection surgeries together with the surgeons of the SIUT. In these seven days the team not only demonstrated the intricacies of liver surgery to their Pakistani colleagues.

Liver surgery inprogress

It also conducted a symposium on liver transplantation and imparted a wealth of knowledge to over 300 doctors who attended.

Liver disease can be quite devastating especially if it strikes a person in his youth. A young woman I know has been on drugs since 1986 when she first had Hepatitis. Once she was very ill and had to stay in the hospital for six weeks. Since 1992 when cirrhosis was diagnosed, she has had to be under the constant supervision of a doctor, has been admitted to the hospital twice and she has to undergo frequent blood tests, ultrasounds and CT scans. Over and above this is the agony of pain and an off and on upset stomach she has had to live with perpetually. Yet she has shown the courage and moral strength to lead a full life in spite of her ill-health.

With the pain of this young woman close to my heart, I found it spiritually enriching to talk to Prof Rela. He was as precise and practical as a good surgeon should be — never exaggerating the benefits nor minimizing the risks liver surgery involves and yet inspiring hope for those so critically ill. Most importantly, he left me feeling confident for the future of the 8000 liver failure patients in Pakistan who die every year.

Prof Mohamad Rela, the liver transplantationspecialist from London

“My unit in London is smaller than the SIUT which has the infrastructure for kidney transplantation (on an average 100 are carried out every year). I don’t see any reason why liver transplantation surgery cannot be done here,” he remarked at the start of the interview. It is strange that there is little realization of the high incidence of liver disorders in Pakistan. Dr Rela said that it was much higher than in Britain. Hepatitis B and C take a heavy toll though immunization vaccines are available and can provide lifelong protection. Hepatitis is a major cause of liver failure — of course it takes years after a person contracts this infection for cirrhosis to develop and for liver failure to set in.

But once the stage is reached when fluid accumulates in the abdomen, mental confusion sets in and the kidneys begin to fail then there is no way of providing relief except by transplanting a healthy organ.

Some metabolic disorders and congenital liver conditions in children also require a transplantation. They prove to be fatal here because liver surgery is not performed in Pakistan. This is more distressing in the case of little children. It is estimated that 2,000 children (may be even more) suffer pain and die in the prime of their life of liver failure in Pakistan every year when their lives could be saved by a liver transplantation.

Dr Rela observes that kidney and liver transplantations go together. “You have the basic structure here. You just need some new equipment, more monitoring facilities, greater intensive care arrangements and personnel with some further training. The immuno-suppressants are the same as those used after a renal transplantation and the doctors at SIUT have a lot of experience in their use. Of course, the surgeons would have to be trained to acquire some further skills,” he says.

He believes it would require a year of intensive training of senior and experienced personnel to qualify them for liver surgery. This doesn’t sound so unachievable after all. But Dr Rela warns of the difficulties involved.

Liver transplantation surgery is more complex than a kidney transplantation. It leaves the patient more ill before recovery begins because of the upset it causes to the body metabolism, calling for greater post-surgical nursing. The operation procedure is more complex, especially in children, and the operation takes longer (five to six hours compared to two-and-a-half hours for a kidney transplant). The post-operative stay in the hospital is also longer.

There are some brighter dimensions too. The liver is an organ, which can regenerate itself. Hence a segmental transplant is possible by removing a part of the living-related donor’s liver which grows back to its normal size in a fortnight. But if more than 50 per cent of the liver is removed it entails serious risks for the donor.

That is the minimum, which must be removed if the transplantation is to succeed. But in a child even as little as 25 per cent of the adult donor’s liver will suffice to make the transplantation successful — albeit the surgical technique calls for greater skill and practice.

Hence for a liver transplantation programme to be feasible in Pakistan, we will have to return to the issue of cadaveric donation of organs. Britain experiences a shortage of organs even though there is greater social awareness there, cadaveric organ donation has been legalized and the incidence of liver disease is not as high as it is here.

Prof Rela says that his unit which is the largest in Europe carries out 200 (of a total of 750 in Britain) liver transplantations in a year of which 60 are children. Yet there are people who are denied this facility, which is funded entirely by the National Health Service, because organs are not available.

In Pakistan the situation will be worse if a similar programme is launched. There is no law on cadaveric organ donation — the draft of the bill has been lying before the Senate since 1994 and in the present constitutional stalemate the bill has no chance of becoming law.

Moreover there is not sufficient awareness about liver disease and transplantation as well as about cadaveric organ donation and brain death. Yet contrary to popular belief, our people are willing to be educated and be enlightened.

The need is for an initiative to launch a campaign to mobilize them. Nothing demonstrated this better than the example of the family of a young man Naveed who was mortally wounded in a road accident in November 1998. He was put on a respirator and then pronounced brain dead by the neurologists. His family donated his kidneys and corneas so that two young men could live a normal healthy life and two sightless people could be blessed with vision.

The message is clear: the dead must give the gift of life to the dying. And we do not have to wait for the law on cadaveric organ donation before we start teaching the people the role they can play in this great moral and medical endeavour.